Transosseous Guide And Method

ABSTRACT

Instruments and methods for surgical transosseous attachment to a bone include a guide able to guide the formation of intersecting bone tunnels and a passer able to pass a member through the bone tunnels.

CROSS-REFERENCE TO RELATED APPLICATIONS

This is a continuation of U.S. patent application Ser. No. 17/068,909filed Oct. 13, 2020, which is a divisional application of U.S. patentapplication Ser. No. 15/887,095 filed Feb. 2, 2018, which is acontinuation-in-part of U.S. patent application Ser. No. 15/211,764filed Jul. 15, 2016 (now U.S. Pat. No. 10,258,401), which claims thebenefit of U.S. Provisional Application No. 62/193,888 filed Jul. 17,2015. U.S. patent application Ser. No. 15/887,095 filed Feb. 2, 2018 isalso a continuation-in-part of U.S. patent application Ser. No.15/211,673 filed Jul. 15, 2016 (now U.S. Pat. No. 10,154,868), whichalso claims the benefit of U.S. Provisional Application No. 62/193,888filed Jul. 17, 2015. Each of the above named applications isincorporated by reference, as if set forth herein in its entirety.

TECHNICAL FIELD

The present disclosure relates to transosseous guides and methods fortransosseous attachments.

BACKGROUND

A variety of surgical procedures require the attachment of somethingrelative to a surgical site. For example, in surgery relating to theskeletal system, it is often advantageous to attach soft tissue, suture,implants, and/or other items in or adjacent to a joint. For example,soft tissues such as ligaments, tendons, fascia, other capsularmaterial, and/or muscle may be attached to an adjacent bone. Such softtissues may be adjacent to bones at skeletal joints including but notlimited to the joints of the hands and feet, ankle, wrist, knee, elbow,hip, shoulder, and spine. For example, it is often advantageous to passa suture through a portion of a bone to form a transosseous attachmentto the bone.

SUMMARY

Examples of the present disclosure provide instruments and methods forsurgical transosseous attachment to a bone.

In one example of the present disclosure, a system for placing aflexible member transosseously through first and second transverse,intersecting bone tunnels may include a guide body having a guide bodyhandle portion and a longitudinal guide body passage. The system mayalso include a first tunnel member engaged with the guide body thatincludes a proximal end, a distal end, a first longitudinal passageextending through the first tunnel member, at least one curved portionnearer the distal end of the first tunnel member than the proximal endof the first tunnel member, and a first guide axis associated with thedistal end of the first tunnel member, where at least a portion of thefirst longitudinal passage near the distal end of the first tunnelmember is coaxial with the first guide axis. The system may also includea second tunnel member engaged with the longitudinal guide body passagethat includes a proximal end, a distal end, and a second longitudinalpassage extending at least partway through the second tunnel member. Thesecond longitudinal passage may be coaxial with a second guide axisdefined by the longitudinal guide body passage when the second tunnelmember is engaged with the longitudinal guide body passage and at leasta portion of the first longitudinal passage near the proximal end of thefirst tunnel member may be parallel to the second guide axis. The systemmay also include a passer operable to extend from the proximal end ofthe first tunnel member, through the distal end of the first tunnelmember, through the distal end of the second tunnel member, and to theproximal end of the second tunnel member in one continuous path.

In another example of the present disclosure, a system for placing amember transosseously through first and second bone tunnels may includea guide body with a longitudinal guide body passage. The system may alsoinclude a first tunnel member engaged with the guide body that has aproximal end, a distal end, and a first longitudinal passage extendingthrough the first tunnel member. The system may also include a secondtunnel member engaged with the longitudinal guide body passage that hasa proximal end, a distal end, and a second longitudinal passageextending at least partway through the second tunnel member. The systemmay also include a passer operable to extend from the proximal end ofthe first tunnel member, through the distal end of the first tunnelmember, through the distal end of the second tunnel member, and to theproximal end of the second tunnel member in one continuous path.

In another example of the present disclosure, a method for placing amember transosseously through first and second transverse, intersectingbone tunnels that includes inserting a first tunnel member into a bonealong a first insertion axis, the first tunnel member having a proximalend, a distal end, and a first longitudinal passage extending throughthe first tunnel member. The method may also include inserting a secondtunnel member into the bone along a second insertion axis thatintersects the first insertion axis, the second tunnel including aproximal end, a distal end, and a second longitudinal passage extendingat least partway through the second tunnel member. The method may alsoinclude inserting a passer through the first and second tunnel membersin one continuous motion until the passer extends through the firstlongitudinal passage, the second longitudinal passage, out of theproximal end of the first tunnel member, and out of the proximal end ofthe second tunnel member.

BRIEF DESCRIPTION OF THE DRAWINGS

Various examples of the present disclosure will be discussed withreference to the appended drawings. These drawings depict onlyillustrative examples of the present disclosure and are not to beconsidered limiting of its scope.

FIG. 1 is a side elevation view of an example of the present disclosureillustrating an instrument engaged with a bone, the bone being shown inpartial section;

FIG. 2 is a side elevation view of an example of a passer used with theinstrument of FIG. 1 ;

FIG. 3 is a detail side elevation view of the tip of the passer of FIG.2 ;

FIG. 4 is a detail front elevation view of the tip of the passer of FIG.2 ;

FIG. 5 is a side elevation view of the instrument of FIG. 1 engaged witha bone and the passer of FIG. 2 inserted through the instrument;

FIG. 6 is a section view taken along line 6-6 of FIG. 1 ;

FIG. 7 is detail side section view of the instrument of FIG. 1 showingthe passer engaged with the instrument in a first position;

FIG. 8 is detail side section view of the instrument of FIG. 1 showingthe passer engaged with the instrument in a second position;

FIG. 9 is a side elevation view of an example of the present disclosureillustrating an alternative arrangement of the instrument of FIG. 1 ;

FIG. 10 is a top plan view of the instrument of FIG. 9 ;

FIG. 11 is a section view taken along line 11-11 of FIG. 10 ;

FIG. 12 is a side elevation view of an example of the present disclosureillustrating an alternative arrangement of the passer of FIG. 2 in afirst position;

FIG. 13 is a side elevation view of the example of FIG. 12 in a secondposition;

FIG. 14 is a partial sectional view of the bone of FIG. 1 after a suturehas been passed and the passing instruments have been removed;

FIG. 15 is a partial sectional view illustrating the suture of FIG. 14in use to secure a soft tissue to the bone;

FIG. 16 is a rear elevation view of the guide of FIG. 1 illustrating howit can be rotated while engaged with a bone;

FIG. 17 is a perspective view of the guide of FIG. 1 illustrating how itcan be rotated while engaged with a bone;

FIGS. 18-28 are perspective views of methods according to examples ofthe present disclosure;

FIGS. 29A and 29B are perspective views of another example guide body ofthe present disclosure;

FIG. 30A is a side elevation view of the guide body of FIGS. 29A and29B;

FIG. 30B is a side section view of the guide body of FIG. 30A;

FIG. 31A is a perspective view of an example second tunnel member thatmay be used with the guide of FIGS. 29A-30B;

FIG. 31B is a side elevation view of the second tunnel member of FIG.31A;

FIG. 31C is a side section view of the second tunnel member of FIG. 31B;

FIG. 32 is a side section view of a bone with a punch inserted into thebone to form a first bone tunnel;

FIG. 33 is a side elevation view of the guide of FIGS. 29A-31C engagedwith the bone of FIG. 32 and a first tunnel member inserted into thefirst bone tunnel;

FIG. 34 is a side elevation view of the guide of FIGS. 29A-31C engagedwith the bone of FIG. 32 and the second tunnel member inserted into thebone;

FIG. 35 is a side elevation view of the guide of FIGS. 29A-31C engagedwith the bone of FIG. 32 and a passer inserted into the first tunnelmember;

FIG. 36 is a side elevation view of the guide of FIGS. 29A-31C engagedwith the bone of FIG. 32 with a passer wire threaded through both tunnelmembers and protruding from the proximal end of the second tunnelmember;

FIG. 37 is a side elevation view of the guide of FIGS. 29A-31C engagedwith the bone of FIG. 32 with a first flexible member engaged with thepasser wire and pulled through both tunnel members;

FIG. 38 is a perspective view of a bone with first and second flexiblemembers passed through the bone; and

FIG. 39 is a flowchart diagram illustrating a method of placing aflexible member transosseously through first and second transverse,intersecting bone tunnels.

DETAILED DESCRIPTION

The following illustrative examples depict instruments and methods toform a tunnel through a bone and pass a member through the bone tunnel.The illustrative examples depict passing a round suture through a bonetunnel to attach soft tissue to the bone. However, the instruments andmethods of the present disclosure may be used to pass other elementsthrough a bone tunnel including, suture passers, suture tapes, cables,soft tissues, grafts, and other elements. Examples of instruments andmethods of the present disclosure may be used to pass any member throughany bone, at surgical sites anywhere in a patient's body, and for anypurpose. The terms “suture” and “suture strand” are used herein to meanany strand or flexible member, natural or synthetic, able to be passedthrough a bone tunnel and useful in a surgical procedure. The term“transverse” is used herein to mean to cross at an angle; i.e. notparallel. The term includes, but is not limited to right angles.

FIGS. 1-8 depict examples of a guide and a passer for formingintersecting bone tunnels in a bone 198 and passing a flexible elementthrough the tunnels. The exemplary guide 100 includes a guide body 102defining a first insertion or guide axis 104 and a second insertion orguide axis 106 intersecting at a location 108 spaced from the guidebody.

A first tunnel member 110 is engageable with the guide body 102 coaxialwith the first guide axis 104 and includes a proximal end 112, a distalend 114, and a first longitudinal passage 116 (FIG. 7 ) at least partwaythrough the first tunnel member 110.

A second tunnel member 120 is engageable with the guide body 102 coaxialwith the second guide axis 106 and includes a proximal end 122, a distalend 124, and a second longitudinal passage 126 (FIG. 7 ) at leastpartway through the second tunnel member 120.

A passer 136 (FIG. 2 ) is operable to extend from the proximal end 122of the second tunnel member 120, through the distal end 124 of thesecond tunnel member 120, through the distal end 114 of the first tunnelmember 110, and to the proximal end 112 of the first tunnel member 110in one continuous path. The passer 136 may then be used to pull aflexible member or element such as, for example, a passing suture or arepair suture through the tunnel members 110, 120 to pass the flexibleelement through, for example, a bone.

In the illustrative embodiment of FIGS. 1-8 , the guide body 102 is madeup of first and second arc members 130, 132. The first and second arcmembers 130, 132 are joined in sliding relationship along an arc shapedpath 134 of constant radius such that the guide 100 is adjustablebetween a first position (shown in solid lines in FIG. 1 ) in which thefirst guide axis and the second guide axis define a first angle betweenthem and a second position (shown in dashed lines in FIG. 1 ) in whichthe first guide axis and the second guide axis define a second, largerangle between them. Preferably, the guide is continuously adjustableover a range of included angles between the first and second guide axes104, 106 of from 20 to 110 degrees. More preferably, the range is 60 to90 degrees. In the illustrative example of FIGS. 1-8 , the first guideaxis 104 is defined by a passage in the first arc member 130 and thesecond guide axis 106 is defined by a passage in the second arc member132.

The first tunnel member may include a drill guide, a punch guide, apunch, or other suitable member for forming a bone tunnel and/or forinserting into a bone tunnel. In the illustrative example of FIGS. 1-8 ,the first tunnel member 110 is a bone punch fixed to the guide body suchas by pinning, threading, welding, or other suitable fixation method.For example, the first tunnel member 110 may be impacted into the bone198 to form a bone tunnel in the bone. In the illustrative example ofFIGS. 1-8 , the first tunnel member 110 includes a cylindrical bodyhaving a first, larger diameter 140 near its proximal end 112 and asecond, smaller diameter 142 near its distal end with a taperedtransition region 144 between the two diameters. The cylindrical bodydefines a first outer side wall and a first recess or side opening 146(FIG. 7 ) in the first side wall nearer the distal end 114 than theproximal end 112. The second guide axis 106 passes through the firstside opening 146 for every angle in the range of adjustment of the firstand second arc members 130, 132. The first longitudinal passage 116extends from the proximal end 112 of the first tunnel member 110 towardthe distal end 114 and communicates with the first side opening 146. Arelief opening 148 in the side wall is positioned opposite the firstside opening 146 and communicates with the first longitudinal passage116 and the first side opening 146. The first tunnel member 110 includesindicia 150 (FIG. 1 ) on the outer surface readable relative to the bonesurface to indicate a depth of penetration of the first tunnel member110 into the bone. In the illustrative example of FIGS. 1-8 , theindicia 150 include two separate marks to indicate the appropriate depthfor two different sizes of anchor. In the illustrative example of FIGS.1-8 , the first tunnel member 110 tapers to a solid, sharp point 152distal to the first side opening 146 and the relief opening tofacilitate driving the first tunnel member 110 into bone.

The second tunnel member may include a drill guide, a punch guide, apunch, or other suitable member for forming a bone tunnel and/orinserting into a bone tunnel. In the illustrative example of FIGS. 1-8 ,the second tunnel member 120 is a punch engageable with the guide 100 inaxial sliding relationship along the second guide axis 106. For example,the second tunnel member 120 may be impacted into the bone 198 to form abone tunnel in the bone. In the illustrative example of FIGS. 1-8 , thesecond tunnel member 120 includes a body having a “D”-shaped proximalportion 160 and a smaller cylindrical distal portion 162 with a taperedtransition region 164 between the two portions. The body defines asecond outer side wall and a second side opening 166 (FIG. 7 ) in thefirst side wall nearer the distal end 124 than the proximal end 122. Inthe illustrative example of FIGS. 1-8 , the second longitudinal passage126 extends from the proximal end 122 of the second tunnel member 120toward the distal end 124 of the second tunnel member 120 andcommunicates with the second side opening 166. The second tunnel member120 tapers to a solid, sharp point 168 distal to the second side opening166 to facilitate driving the second tunnel member 120 into bone. Thesecond tunnel member 120 includes an indicator to indicate when it isengaged with the first tunnel member 110. In one example, the secondtunnel member 120 includes an index mark 170 on the outer surfacereadable relative to the guide 100 to indicate a depth of penetration ofthe second tunnel member 120 into the bone. In the illustrative exampleof FIGS. 1-8 , the distal portion 162 of the second tunnel member 120 isengageable within the first side opening 146 of the first tunnel memberwith the first side opening 146 and second side opening 166 incommunication with one another. The index mark 170 on the second tunnelmember 120 indicates when the distal end of the second tunnel member 120is seated in the first side opening 146. In another example, the secondtunnel member 120 has an elongated marker such as for example acontrasting surface 171 that is exposed to indicate when the secondtunnel member is not properly seated. The surface 171 extendsproximally-distally the distance of the engagement of the second tunnelmember 120 with the guide body 102. When the second tunnel member 120 isproperly seated, the surface 171 is covered by the guide body 102. Ifthe second tunnel member 120 is not fully seated, the surface 171 isvisible above the guide body. If the second tunnel member is insertedtoo far, for example if it deflects upon insertion such that it missesthe first tunnel member and is driven past the first tunnel member, thesurface 171 is visible below the guide body. In one example, the surface171 includes a colored stripe, for example a red colored stripe, suchthat if red is visible after inserting the second tunnel member itindicates that the second tunnel member is not properly seated. Forexample, in FIGS. 1 and 21 the surface 171 is visible above the guidebody 102 and in FIGS. 5 and 22 the surface 171 is concealed by the guidebody 100.

The relief opening 148 in the first tunnel member allows bone chips orother debris to exit the first tunnel member 110 when the second tunnelmember 120 engages it. In the illustrative example of FIGS. 1-8 , anangled surface 172 is formed at the distal end of the secondlongitudinal passage 126 facing the second side opening 166. The angledsurface 172 deflects the passer 136 through the second side opening 166and into the first longitudinal passage 116 when the passer is inserted.The “D”-shape of the proximal portion 160 of the second tunnel member120 engages the guide 100 to prevent rotation of the second tunnelmember 120 as it axially translates so that the first and second sideopenings 146, 166 are aligned when the first and second tunnel members110, 120 are engaged.

The length of the first and second tunnel members 110, 120 that extendsfrom the guide body to their intersection location may be any desiredlength. However, it has been found by the inventors that for rotatorcuff repair surgery on a human shoulder, a length of each member in therange of 2-8 inches is useful. More preferably the length is in therange of 4-6 inches. The length for each member may be the same ordifferent. In the example of FIGS. 1-8 , the length of the first tunnelmember extending from the guide body is approximately 5.5 inches and thelength of the second tunnel member extending from the guide body isapproximately 4.5 inches.

The passer 136 includes a first, or proximal, end 180 and a second, ordistal, end 182 defining a loop 188. In the illustrative example ofFIGS. 1-8 , the passer 136 includes a relatively rigid shaft 184extending away from the first end and a relatively flexible wire 186attached to the shaft 184 and extending away from the shaft 184. In oneexample, the shaft 184 is a tubular member and the wire 186 is crimped,bonded, soldered, welded or otherwise attached to the shaft. In theillustrative example of FIGS. 1-8 , the wire 186 is formed into a loop188 in a first plane and bent to form a curved profile 190 in a secondplane perpendicular to the first plane. The curved profile 190 of thewire and the angled surface 172 at the distal end of the secondlongitudinal passage 126 cooperate to facilitate advancing the distalend 182 of the passer from the second longitudinal passage 126 into thefirst longitudinal passage 116. The passer 136 includes a handle 192 atthe proximal end 180. Preferably, the passer, or at least the wire 186,is formed of a super elastic material such as nitinol, as onenon-limiting example. Preferably the combined length of the shaft 184and wire 186 is greater than the combined length of the first and secondlongitudinal passages 116, 126 such that the passer 136 is insertablethrough the first and second tunnel members 110, 120 to extend throughthe first and second axial passages and out of the proximal end 112 ofthe first tunnel member 110 and out of the proximal end 122 of thesecond tunnel member 120. For example, as the distal end 182 of thepasser reaches the distal end of the second longitudinal passage 126, itabuts the angled surface 172 and is deflected out through the secondside opening 166, through the first side opening 146 and into the firstlongitudinal passage 116 (FIG. 7 ). The curved profile 190 of the wireand angled surface 172 facilitate the transition of the wire 186 fromthe second tunnel member 120 to the first tunnel member 110 and promotepassage even when the first and second tunnel members 110, 120 areengaged at an acute angle. The passer is further advanced to move thedistal end 182 of the passer through the second longitudinal passage andout the proximal end 112 of the first tunnel member 110 (FIG. 5 ). Amember 191, e.g. a suture, may be placed in the loop 188 at the distalend 182 of the passer and the passer 136 may be retrieved to pull themember 191 through the first longitudinal passage 116, through the firstside opening 146, through the second side opening 166, through thesecond longitudinal passage 126 and out the proximal end of the secondlongitudinal passage 126. The passer handle includes an indicator, forexample a flat surface 197, to indicate to a user the orientation of thebent loop 188 so that the user can orient it to engage the angledsurface 172. Alternatively, or in addition, the passer may be keyed tothe second tunnel member to permit only one orientation.

FIGS. 9-11 illustrate another example of a guide instrument 300 similarto that of FIG. 1 but showing a different arrangement of the secondguide axis. The guide body 302 includes a first tunnel member 304 likethe first tunnel member in the example of FIG. 1 that defines a firstguide axis 306 as with the example of FIG. 1 . However, the guide bodyis a unitary body having a plurality of receivers 308, 310, 312, 314,316, 318, 320 operable to receive the second tunnel member 120. Eachreceiver includes a passage defining a guide axis. Any number ofreceivers may be included at any desired spacing to provide a desiredselection of guide angles relative to the first guide axis. In theexample of FIGS. 9-11 , seven receivers are provided defining a secondguide axis 328, a third guide axis 330, a fourth guide axis 332, a fifthguide axis 334, a sixth guide axis 336, a seventh guide axis 338, and aneighth guide axis 340. Each of the second through eighth guide axesintersects the first guide axis 304 at the same location spaced from theguide body and each can selectively receive the second tunnel member. Inthe example of FIGS. 9-11 , each of the second through eighth guide axesintersects a side opening 346 in the first tunnel member like the sideopening 146 in the example of FIG. 1 . A surface 333 formed at thedistal end of each receiver engages the flat side of the “D”-shapedsecond tunnel member 120 to prevent rotation of the second tunnel member120 within the receiver so that the first and second side openings 146,346 are properly aligned when the first and second tunnel members areengaged.

In the example of FIGS. 9-11 , the second through eighth guide axes areequally spaced and define angles of 45 degrees to 75 degrees relative tothe first guide axis 306. Indicia 350 on the first tunnel member 304indicates an insertion depth range suitable for a fastener, for examplea knotless fastener. Indicia 351 on each receiver indicates the anglecorresponding to each receiver. The spacing can be any desired spacingand can be uniform or non-uniform to provide a range of angles useful tothe user. The inventors have found the spacing and range shown in theexample to be suitable for typical rotator cuff procedures of the humanshoulder.

For other applications, such as for example for attaching soft tissue toa bone adjacent a knee joint, ankle, or other location, differentspacing and angular range may be desirable. Similarly, the length of thefirst and second tunnel member may be varied. For example, for repairinga torn Achilles tendon, a guide having an angular range of 50 to 80degrees has been found suitable with either a sliding adjustable guidelike that of FIG. 1 or a unibody guide like that of FIG. 9 . In aunibody guide, four receivers defining axes at 50, 60, 70 and 80 degreesrelative to the first guide axis have been found to be suitable. Anylength of first and second tunnel members may be used. However, forrepairing a torn Achilles tendon, shorter lengths may advantageously beused. For example, first and second tunnel members each extending fromthe guide body a distance in the range of two to three inches has beenfound suitable.

FIGS. 12-13 illustrate another arrangement for a passer 400 similar tothat of FIG. 2 . The passer 400 includes an outer tube 402 engagedcoaxially with the shaft 484 in axial sliding relationship and moveablerelative to the shaft from a first position in which the outer tubeencloses a portion of the wire length (FIG. 13 ) and a second positionin which the outer tube encloses less of the wire length (FIG. 12 ). Theouter tube is relatively rigid relative to the wire 486. The outer tubeaids in inserting the passer 400 into the second tunnel member byholding the wire 486 in a straight and rigid configuration when the tubeis in the first position. The outer tube may enclose any portion of thewire length in the first position to aid in inserting the passer.Preferably, in the first position, the outer tube encloses more thanone-half of the wire length; more preferably 60 to 100 percent of thewire length; more preferably 80 to 100 percent of the wire length; morepreferably the entire wire length including all of the loop 488. In thesecond position, enough of the wire is exposed to allow it to extendthrough the side openings in the first and second tunnel members andthrough the first tunnel member. Preferably in the second position, theouter tube encloses less than one-half of the wire length; morepreferably less than 20 percent of the wire length. The tube may beinserted into the second tunnel member while in the first position andthen shaft 484 advanced to extend the wire 486 out of the outer tube 402and through the second and first tunnel members. For example, a handle492 on the shaft may be pressed toward a handle 493 on the outer tube toadvance the wire. The loop 488 in the example of FIGS. 12 and 13includes a first bend 487 angled away from the main portion of the wire486 and a second bend 489 at the distal end forming a small radius. Thebends 487, 489 facilitate the transition of the loop through the sideopenings of the tunnel members.

The exemplary guides and methods of the present disclosure make itpossible to form intersecting bone tunnels in a bone and extend, in onemotion, a passer through the guide and bone tunnels from a firstposition external to the bone to a second position external to the bone.A first end of a member, such as a suture, may then be engaged with thepasser outside of the bone tunnels. By having the engaging step outsideof the bone tunnels, it may be done with simple manual manipulation ofthe passer loop and the first end of the member with easy access andvisibility and without specialized arthroscopic instrument orprocedures. The first end of the member may then be passed, in onemotion, through the guide and bone tunnels from the second positionexternal to the bone to a first position external to the bone to threadthe member through the intersecting bone tunnels. The member may be usedin any desirable manner. For example, a member in the form of a suture194 may be so passed and then used to secure soft tissue 196 to the bone198 as shown in FIGS. 14 and 15 .

Referring to FIGS. 16 and 17 , a guide according to examples of thepresent disclosure, for example guide 100 as shown in FIGS. 16 and 17 ,may be used to create three or more intersecting tunnels and passflexible elements through the tunnels. For example, after passing afirst flexible element through first and second intersecting tunnels ina bone 198, the second tunnel member 120 may be withdrawn from the bone.The guide 100 may be rotated about the first guide axis 104, as shown atreference numeral 193, and/or the angle between the guide axes 104 maybe adjusted as shown at reference numeral 195 in FIG. 17 . In a unitaryguide such as the example of FIG. 9 , the angle between the guide axesmay be adjusted by inserting the second tunnel member in a differentreceiver. The second tunnel member 120 may then be inserted into thebone 198 in a new location and advanced to form a third bone tunnelintersecting the first bone tunnel. The second tunnel member 120 may beengaged with the first tunnel member 110 and the passer 136 used to passa second flexible element through the first and third tunnels. This maybe repeated as many times as desired to provide a one-to-manyrelationship between the first bone tunnel and the plurality ofadditional bone tunnels intersecting the first bone tunnel. The thirdand subsequent bone tunnels may be formed and the second and subsequentflexible elements may be passed while the first tunnel member 110remains in the bone and while the first flexible element remains in thefirst tunnel member.

FIGS. 18-27 illustrate an example of a surgical method according to thepresent disclosure. In the illustrative example of FIGS. 18-27 ,instruments and methods of the previous examples are shown in use toplace transosseous sutures to repair a rotator cuff 202 of a shoulderjoint. It will be understood that any of the examples of instruments andmethods of the present disclosure may be used in any combination to passa member through a shoulder bone or other bones at a shoulder or othersurgical sites and for rotator cuff repair or other surgical purposes.

Referring to FIG. 18 the guide 100 is positioned with the point 152 ofthe first tunnel member 110 on the lateral surface of the greatertuberosity 200 of the humerus approximately 30 mm inferior to thesuperior border of the tuberosity. The guide 100 is oriented such thatit is perpendicular to the long axis of the humerus and perpendicular tothe acromion (not shown).

Referring to FIG. 19 , the first tunnel member 110 is impacted into thebone to form a first, or lateral, bone tunnel 210.

Referring to FIG. 20 , the location for a second, or medial, tunnel isvisualized using a targeting wire 204 in a targeting sleeve 206 toconstrain the wire 204 to translation along the second guide axis 106.The position of the targeting wire may be adjusted in two degrees offreedom. First, the guide 100 may be rotated about the first guide axis104 by twisting the first tunnel member 110 in the lateral bone tunnel210. Second, the guide may be repositioned by adjusting the first andsecond arc members 130, 132 to change the angle between the guide axes104, 106 (or repositioning the targeting sleeve and targeting wire in adifferent receiver in a unitary guide such as that of FIG. 9 ). As theseadjustments are made, the targeting wire 204 may be inserted through theskin and other soft tissues near the targeted site so that the positionmay be visualized on the bone. The small punctures in the skin and othersoft tissues created by the targeting wire 204 cause minimal trauma tothe tissues and facilitate multiple targeting attempts if needed. Thetargeting wire 204 is then used to mark the bone surface with thedesired medial tunnel location.

Referring to FIG. 21 , the targeting sleeve and wire are removed and thesecond tunnel member 120 is impacted to form a second, or medial, tunnel212.

Referring to FIG. 22 , the second tunnel member 120 is engaged with thefirst tunnel member 110 and the passer 400 inserted into the secondtunnel member 120.

Referring to FIG. 23 , the wire is advanced through the first and secondtunnel members 110, 120 until it extends from the proximal end of thefirst tunnel member 110. The end 216 of a first shuttle suture 214 ispassed through the loop 488 of the passer 400.

Referring to FIG. 24 , the end 216 of the shuttle suture 214 isretrieved by pulling the passer 136 out the distal end of the secondtunnel member 120.

Referring to FIG. 25 , the second tunnel member 120 is removed leavingthe first shuttle suture 214 in place in the first tunnel member 110 andextending out of the second, medial bone tunnel 212.

Referring to FIGS. 26 and 27 , the preceding steps are repeated tocreate a third, additional medial, tunnel 218 and place a second shuttlesuture 219 while the first tunnel member 110 remains in the bone andwhile the first shuttle suture 214 remains in the first tunnel member110. Two limbs 220, 222 of a first repair suture are passed through theloop of the first shuttle suture 214 and two limbs 224, 226 of a secondrepair suture are passed through the loop of the second shuttle suture219. The shuttle sutures 214, 219 are pulled to pass the limbs of therepair sutures through the bone. The repair sutures are passed throughthe rotator cuff 202 and used to secure it to the humerus 200.

Referring to FIG. 28 the instruments and methods may also be used forother repairs such as, for example, an Achilles tendon repair in whichthe first and second tunnel members are inserted into the heel bone 500and one or more sutures are passed and used to secure the Achillestendon 502 to the bone 500.

While the illustrative examples have shown bone tunnels being formed bypunching instruments into the bone, it is also within the scope of thepresent disclosure to form bone tunnels by drilling, reaming, broaching,and/or any suitable tunnel forming process. It is contemplated, andwithin the scope of the present disclosure, that the various features ofthe illustrative examples may be interchanged among the illustrativeexamples.

FIGS. 29A-31C depict another example surgical instrument or guide 600that may be used place a flexible member transosseously through firstand second bone tunnels oriented transverse to each other andintersecting one other at a location within a bone. FIGS. 32-39 depictmethods for placing a flexible member transosseously through first andsecond transverse, intersecting bone tunnels utilizing the guide 600shown in FIGS. 29A-31C.

Referring now to FIGS. 29A-30B, the guide 600 may include a guide body602. The guide body 602 may include a first tunnel member 610, alongitudinal guide body passage 632 (FIG. 30B), a guide body handleportion 630, and a detent mechanism 640.

The first tunnel member 610 may be engaged with the guide body 602 in afixed fashion, or in a removably engaged fashion, and may include aproximal end 612, a distal end 614, a distal opening 646, a curvedportion 634 that is nearer the distal end 614 than the proximal end 612of the first tunnel member 610, and a first longitudinal passage 616(FIG. 30B) that extends through the first tunnel member 610 andcommunicates with the distal opening 646. In one embodiment, the curvedportion 634 may include a first bend 631, a second bend 633, a thirdbend 635, a first straight segment 636 and a second straight segment637. However, in other embodiments (not shown) the curved portion 634may include a single continuous bend, or any number of bends and/or anynumber of straight segments, without departing from the spirit or scopeof the present disclosure. The distal end 614 of the first tunnel member610 may define a first guide axis 604 and at least a portion of thefirst longitudinal passage 616, near the distal end 614 of the firsttunnel member 610, may be coaxial with the first guide axis 604.

The longitudinal guide body passage 632 may be formed in the guide body602 and may define a second guide axis 606. The first guide axis 604 andthe second guide axis may be configured to intersect each other at alocation spaced from the guide body 602 and at least a portion of thefirst longitudinal passage 616 near the proximal end 612 of the firsttunnel member 610 may be parallel with the second guide axis 606 and/orparallel with the longitudinal guide body passage 632.

The detent mechanism 640 may be formed in the guide body handle portion630 and may include a spring-biased ball plunger 642 that protrudes intothe longitudinal guide body passage 632, as will be explained in moredetail below.

Referring now to FIGS. 31A-31C, the guide 600 may include a secondtunnel member 620. In at least one embodiment, the second tunnel member620 may be a bone punch that is removably engaged with the longitudinalguide body passage 632. In this manner, the second tunnel member 620 maybe separable from the guide body 602 and may engage the guide body 602in an axial sliding relationship along the second guide axis 606 withinthe longitudinal guide body passage 632. The second tunnel member 620may include a proximal end 622, a distal end 624, a second longitudinalpassage 626, a side wall 667, a side opening 666, a sharp point 668, anannular notch 644, a handle 650, a first aperture 652 formed in thehandle 650, and a second aperture 654 formed in the handle 650.

The second longitudinal passage 626 may extend at least partway throughthe second tunnel member 620 and the second longitudinal passage 626 maybe coaxial with the second guide axis 606 when the second tunnel member620 is engaged within the longitudinal guide body passage 632.

As previously discussed, the detent mechanism 640 may be configured toengage and retain the second tunnel member 620 in a desired axialposition relative to the guide body 602, causing the second tunnelmember 620 to resist axial movement along the second guide axis 606. Theannular notch 644 that is formed in the side wall 667 of the secondtunnel member 620 may have a complementary shape that interacts with thespring-biased ball plunger 642 of the detent mechanism 640 to resistaxial sliding of the second tunnel member 620 within the longitudinalguide body passage 632. This feature may help prevent the second tunnelmember 620 from accidentally falling out of the longitudinal guide bodypassage 632 as the guide 600 is moved about during surgical procedures.The spring-biased ball plunger 642 may achieve this function by engagingwithin the annular notch 644 and resisting axial sliding of the secondtunnel member 620 due to a spring-biased forced that is placed upon theball plunger. However, the surgeon can still freely rotate the secondtunnel member 620 within the longitudinal guide body passage 632 becausethe spring-biased ball plunger 642 will remain within the annular notch644 as the second tunnel member 620 is rotated within the longitudinalguide body passage 632. Moreover, sufficient axial force may be appliedto the second tunnel member 620 to overcome the force of thespring-biased ball plunger 642 and eject the spring-biased ball plunger642 from within the annular notch 644 and freely slide the second tunnelmember 620 axially within longitudinal guide body passage 632.

The side opening 666 may be formed in the side wall 667 nearer thedistal end 624 of the second tunnel member 620 than the proximal end 622of the second tunnel member 620. The second longitudinal passage 626 mayextend from the proximal end 622 of the second tunnel member 620 towardthe distal end 624 of the second tunnel member 620 and may communicatewith the side opening 666. The side opening 666 formed in the secondtunnel member 620, and the distal opening 646 of the first tunnel member610, may be in communication with each other when the second tunnelmember 620 is axially translated such that the first guide axis 604intersects the side opening 666 of the second tunnel member 620.

FIGS. 35-37 show how the guide 600 may be used with a passer, such asthe passer 400 shown in FIGS. 12-13 . The passer 400 may be operable toextend from the proximal end 612 of the first tunnel member 610, throughthe distal end 614 of the first tunnel member 610, through the distalend 624 of the second tunnel member 620, and to the proximal end 622 ofthe second tunnel member 620 in one continuous path. The passer 400 maythen be used to pull a flexible member 714 such as, for example, apassing suture or a repair suture through the tunnel members 610, 620 topass the flexible member 714 through the bone 698.

FIGS. 32-38 illustrate an example of a surgical method according to thepresent disclosure. In the illustrative example of FIGS. 32-38 ,instruments and methods of the previous examples are shown in use toplace transosseous sutures to repair a rotator cuff of a shoulder joint.However, it will be understood that any of the examples of instrumentsand methods of the present disclosure may be used in any combination topass a member through a shoulder bone or other bones at a shoulder orother surgical sites and for rotator cuff repair and/or other surgicalpurposes.

Referring to FIG. 32 , a tool 800, such as a medial bone punch, a bonedrill, etc., may be used to form a first bone tunnel in the bone 698.

Referring to FIG. 33 , the guide 600 may be placed proximal the bone 698with the distal end 614 of the first tunnel member 610 inserted into thefirst bone tunnel that was formed by the tool 800 in FIG. 33 . The guide600 may be rotated back and forth, and pitched up and down, while thefirst tunnel member 610 is inserted into the first bone tunnel toposition the sharp point 668 of the second tunnel member 620 at thedesired location on the surface of the bone 698 before punching thesecond bone tunnel into the bone 698 using the second tunnel member 620.For example, the desired location of the sharp point 668 of the firsttunnel member 110 on the surface of the bone 698 may be on the lateralsurface of the greater tuberosity 699 of the humerus approximately 30 mminferior to the superior border of the tuberosity. The guide 600 may beoriented such that it is perpendicular to the long axis of the humerusand perpendicular to the acromion (not shown).

Referring to FIG. 34 , the second tunnel member 620 may be impacted intothe bone 698 to form the second bone tunnel. The second tunnel member620 may also be rotated/oriented to engage the distal opening 646 of thefirst tunnel member 610 with the side opening 666 of the second tunnelmember 620, such that the distal opening 646 of the first tunnel member610 and the side opening 666 of the second tunnel member 620 are incommunication with each other.

Referring to FIG. 35 , the passer 400 may be inserted into the proximalend 612 of the first tunnel member 610.

Referring to FIG. 36 , the wire 486 of the passer 400 may be advancedthrough the first tunnel member 610, into the second tunnel member 620,and then further advanced until the bent loop 488 on the end of the wire486 protrudes from the proximal end 622 of the second tunnel member 620.

Referring to FIG. 37 , the first flexible member 714 may be passedthrough the bent loop 488 of the wire 486, to engage the first flexiblemember 714 with the passer 400, and the first flexible member 714 maythen be threaded through the tunnel members 610, 620 (and the bonetunnels) by pulling the wire 486 out of the proximal end 612 of thefirst tunnel member 610.

Referring to FIG. 38 , the first tunnel member 610 and the second tunnelmember 620 are removed from the bone tunnels, along with the guide 600,leaving the first flexible member 714 in place in the bone 698.Moreover, the preceding steps may be repeated to create additional bonetunnels and place a second flexible member 719 (or more flexiblemembers, as desired), as shown in FIG. 38 .

Referring now to FIG. 39 , a flowchart diagram is shown of a method 1000of placing a flexible member transosseously through first and secondtransverse, intersecting bone tunnels, according to embodiments of thepresent disclosure. The method 1000 may be carried out through the useof any of the surgical instruments of FIGS. 1-37 . Alternatively, themethod 1000 may be carried out with surgical instruments different fromthose shown in FIGS. 1-37 and/or described elsewhere herein.

The method 1000 may begin with a step 1002, in which a first bone tunnelmay be formed in a bone 698. The first bone tunnel may be sized andconfigured to receive a first tunnel member 610 therein.

The method 1000 may then proceed to a step 1004, in which a first tunnelmember 610 may be inserted into the first bone tunnel of the bone 698along a first insertion axis 604. The first tunnel member 610 mayinclude a proximal end 612, a distal end 614, and a first longitudinalpassage 616 extending through the first tunnel member 610.

The method 1000 may then proceed to a step 1006, in which a secondtunnel member 620 may be inserted into the bone 698 along a secondinsertion axis 606 and the second insertion axis 606 may intersect thefirst insertion axis 604. The second tunnel member 620 may be punchedinto the bone 698 to form a second bone tunnel and insert the secondtunnel member 620 into the bone 698 along the second insertion axis 606after the first tunnel member 610 has been inserted into the first bonetunnel. The second tunnel member 620 may include a proximal end 622, adistal end 624, and a second longitudinal passage 626 extending at leastpartway through the second tunnel member 620.

The method 1000 may then proceed to a step 1008, in which a passer 400may be inserted through the first and second tunnel members 610, 620 inone continuous motion until the passer 400 extends through the firstlongitudinal passage 616, the second longitudinal passage 626, out ofthe proximal end 612 of the first tunnel member 610, and out of theproximal end 622 of the second tunnel member 620.

In other words, the passer 400 may be inserted through the first andsecond tunnel members 610, 620 by inserting the passer 400 so that itextends between the proximal end 612 of the first longitudinal passage616, the distal end 614 of the first longitudinal passage 616, thedistal end 624 of the second longitudinal passage 626, and the proximalend 622 of the second longitudinal passage 626 by advancing the passer400 into the proximal end 612 of the first tunnel member 610, along thefirst longitudinal passage 616, through a distal opening 646 in thefirst tunnel member 610, through a side opening 666 in the second tunnelmember 620, along the second longitudinal passage 626, and out aproximal end 622 of the second tunnel member 620 in one continuousmotion.

The passer 400 may also include a wire 486 forming a loop 488 in a firstplane, the loop 488 being bent so that a portion of the loop 488 forms acurved profile in a second plane perpendicular to the first plane and anouter tube 402 that is moveable relative to the wire 486 between a firstposition in which the outer tube 402 encloses a portion of a length ofthe wire 486 and a second position in which the outer tube 402 enclosesless of the length of the wire 486. The wire 486 may be inserted intothe first tunnel member 610 while the outer tube 402 is positioned inthe first position and the outer tube 402 may be subsequently moved tothe second position to pass the loop 488 from the distal opening 646 inthe first tunnel member 610 through the side opening 666 in the secondtunnel member 620 and out the proximal end 622 of the second tunnelmember 620.

The method 1000 may then proceed to a step 1010, in which a firstflexible member 714 may be engaged with the loop 488 of the passer 400.

The method 1000 may then proceed to a step 1012, in which the passer 400may be withdrawn from the proximal end 612 of the first tunnel member610 to pass the first flexible member 714 through the first and secondtunnel members 610, 620 and the first and second bone tunnels.

The method 1000 may then proceed to a step 1014, in which the firstflexible member 714 may be passed through soft tissue (not shown)adjacent to the bone 698.

The method 1000 may then proceed to a step 1016, in which the firstflexible member 714 may then be used to secure the soft tissue to thebone 698.

Alternatively, or in addition thereto, the method 1000 may proceed to astep 1018, in which the soft tissue may be secured to the bone 698 byinserting a knotless anchor (not shown) into the first bone tunnel andsecuring the first flexible member 714 with the knotless anchor, and themethod 1000 may end.

All methods disclosed herein may be implemented in a wide variety ofways. Although the various steps of the methods disclosed herein areshown and described in a certain order, those of skill in the art willrecognize that the steps of the methods disclosed herein may be executedin many different order combinations from those set forth in thedescriptions of their corresponding Figures. Furthermore, some of thesteps of the methods disclosed herein are optional and may be omittedand/or replaced with other steps not specifically described herein.

Exemplary embodiments of the disclosure will be best understood byreference to the drawings, wherein like parts are designated by likenumerals throughout. It will be readily understood that the componentsof the disclosure, as generally described and illustrated in the Figuresherein, could be arranged and designed in a wide variety of differentconfigurations. Thus, the preceding detailed description of theembodiments of the apparatus, system, and method, as represented in theFigures, is not intended to limit the scope of the disclosure, asclaimed, but is merely representative of exemplary embodiments of thedisclosure.

Reference throughout this specification to “an embodiment” or “theembodiment” means that a particular feature, structure or characteristicdescribed in connection with that embodiment is included in at least oneembodiment. Thus, the quoted phrases, or variations thereof, as recitedthroughout this specification are not necessarily all referring to thesame embodiment.

Similarly, it should be appreciated that in the above description ofembodiments, various features are sometimes grouped together in a singleembodiment, Figure, or description thereof for the purpose ofstreamlining the disclosure. This method of disclosure, however, is notto be interpreted as reflecting an intention that any claim require morefeatures than those expressly recited in that claim. Rather, as thefollowing claims reflect, inventive aspects lie in a combination offewer than all features of any single foregoing disclosed embodiment.Thus, the claims following this Detailed Description are herebyexpressly incorporated into this Detailed Description, with each claimstanding on its own as a separate embodiment. This disclosure includesall permutations of the independent claims with their dependent claims.

The word “exemplary” is used herein to mean “serving as an example,instance, or illustration.” Any embodiment described herein as“exemplary” is not necessarily to be construed as preferred oradvantageous over other embodiments. While the various aspects of theembodiments are presented in drawings, the drawings are not necessarilydrawn to scale unless specifically indicated.

Recitation in the claims of the term “first” with respect to a featureor element does not necessarily imply the existence of a second oradditional such feature or element. Elements recited inmeans-plus-function format are intended to be construed in accordancewith 35 U.S.C. § 112 paragraph 6. It will be apparent to those havingskill in the art that changes may be made to the details of theabove-described embodiments without departing from the underlyingprinciples of the disclosure.

The phrases “connected to,” “coupled to” and “in communication with”refer to any form of interaction between two or more entities, includingmechanical, electrical, magnetic, electromagnetic, fluid, and thermalinteraction. Two components may be functionally coupled to each othereven though they are not in direct contact with each other. The term“abutting” refers to items that are in direct physical contact with eachother, although the items may not necessarily be attached together. Thephrase “fluid communication” refers to two features that are connectedsuch that a fluid within one feature is able to pass into the otherfeature.

While specific embodiments and applications of the present disclosurehave been illustrated and described, it is to be understood that thedisclosure is not limited to the precise configuration and componentsdisclosed herein. Various modifications, changes, and variations whichwill be apparent to those skilled in the art may be made in thearrangement, operation, and details of the methods and systems of thepresent disclosure disclosed herein without departing from the spiritand scope of the disclosure.

What is claimed is:
 1. A method for placing a member transosseously through first and second transverse, intersecting bone tunnels, the method comprising: inserting a first tunnel member into a bone along a first insertion axis, wherein a first longitudinal passage extends through the first tunnel member; inserting a second tunnel member into the bone along a second insertion axis, the second insertion axis intersecting the first insertion axis, wherein a second longitudinal passage extends at least partway through the second tunnel member; and inserting a passer through the first and second tunnel members in one continuous motion until the passer extends through the first longitudinal passage, the second longitudinal passage, out of a proximal end of the first tunnel member, and out of a proximal end of the second tunnel member.
 2. A system for placing a flexible member transosseously through first and second bone tunnels, the first and second bone tunnels oriented transverse to each other and intersecting one other, the system comprising: a guide body having a guide body handle portion and a longitudinal guide body passage; a first tunnel member engaged with the guide body, wherein a first longitudinal passage extends through the first tunnel member, the first tunnel member having at least one curved portion nearer a distal end of the first tunnel member than a proximal end of the first tunnel member; and a first guide axis associated with the distal end of the first tunnel member, wherein at least a portion of the first longitudinal passage near the distal end of the first tunnel member is coaxial with the first guide axis; a second tunnel member engaged with the longitudinal guide body passage, wherein a second longitudinal passage extends at least partway through the second tunnel member, the second longitudinal passage coaxial with a second guide axis defined by the longitudinal guide body passage when the second tunnel member is engaged with the longitudinal guide body passage; and a passer operable to extend from the proximal end of the first tunnel member, through the distal end of the first tunnel member, through a distal end of the second tunnel member, and to a proximal end of the second tunnel member in one continuous path.
 3. A system for placing a member transosseously through first and second bone tunnels, the system comprising: a guide body having a longitudinal guide body passage; a first tunnel member engaged with the guide body, wherein a first longitudinal passage extends through the first tunnel member; a second tunnel member engaged with the longitudinal guide body passage, wherein a second longitudinal passage extends at least partway through the second tunnel member; and a passer operable to extend from a proximal end of the first tunnel member, through a distal end of the first tunnel member, through a distal end of the second tunnel member, and to a proximal end of the second tunnel member in one continuous path. 